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The Yemeni mothers and children dying without medical care

COMPLICATEDDELIVERY

Complicated delivery The Yemeni mothers and children dying without medical care 3

CREDITS© 2019 Médecins Sans FrontièresCover image © Matteo Bastianelli Two premature twins closely monitored at the neonates department of the MSF run “Mother and Child”. Taiz Houban. Yemen

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COMPLICATED DELIVERY

TAIZ HOUBAN MOTHER AND CHILD HOSPITAL AND ABS HOSPITAL, HAJJAH

ACCESS TO MEDICAL CARE

THE IMPACT OF THE ECONOMIC COLLAPSE ON MEDICAL CARE

SAFETY AND SECURITY WHEN SEEKING MEDICAL CARE

MEDICAL CONSEQUENCES OF IMPEDED ACCESS TO HEALTHCARE

CONCLUSION

THE YEMENI MOTHERS AND CHILDREN DYING WITHOUT MEDICAL CARE

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4 Complicated delivery The Yemeni mothers and children dying without medical care

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After four years of conflict, the medical and humanitarian situation in Yemen continues to deteriorate due to violent clashes, continuous airstrikes, political interference in aid operations by warring parties, and an economic maelstrom in what was already the poorest country in the Middle East.

For Yemenis living through this protracted crisis, getting hold of

the essentials of daily life is a constant struggle. This is especially

true of medical care, as Yemen’s public health system is far from

meeting the needs of the country’s 28 million people.

In March 2015, the conflict in Yemen escalated when Ansar

Allah (also known as the Houthi movement) took control

over Sana’a and continued advancing south, then the Saudi

and Emirati-led coalition (SELC) started its campaign of aerial

bombardment in support of the internationally recognised

Government.

Since 2015, Yemen’s public health infrastructure has collapsed

under the strain of displacement, violence and health authority

funding cuts, as well as the dissolution – and duplication – of

state institutions. According to the World Health Organization,

of the 3,507 health facilities it surveyed in 2016, more than

50 percentwereeithernonorpartiallyfunctional.Thesame

survey reported just 6.2 hospital beds per 10,000 people were

available – well under the recommended minimum of 10 per

bedsper10,000 people.Italsofoundthat42percentofthe

districts surveyed had just two doctors, or fewer, present.1

The lack of functioning health facilities and public

vaccination programmes has seen a resurgence of deadly

vaccine-preventable diseases such as cholera, measles and

diphtheria, while disruption to the movement of medical

and humanitarian aid is commonplace.

Today, the ability of Yemenis to access private or public

healthcare has dramatically diminished, as the conflict

has ravaged the economy and devalued people’s savings.

Receiving treatment in a private clinic was a significant and

widely affordable part of Yemen’s pre-conflict health system,

but this is now out of the reach of all but a limited section

of Yemeni society, leaving the vast majority reliant on a

hollowed-out public health service.

The country is exceptionally dependent on imports of food

and fuel. Before the escalation of the conflict, 80 to 90

percent of staple foods and an estimated 544,000 metric

tons of fuel were imported each month.2 Currently, only

around half of the fuel that Yemen needs is entering the

country, causing increased transport and energy costs. This

has negatively affected all sectors of the economy, and hit the

poorest people hardest.

While medical needs are significant across all demographic

groups, those of mothers and children are alarming. Despite

weaknesses in Yemen’s public health system before 2015,

there had been a steady decline in infant and maternal

mortality. However, since the outbreak of the current conflict,

these improvements have reversed.3

The reduced number of functioning health facilities, the

economic damage wrought by the conflict, and the physical

barriers of active fighting and shifting frontlines, all combine

to make reaching medical care a difficult and often dangerous

process. As a result, women and children often arrive so late at

medical facilities that their lives cannot be saved.

1 World Health Organization, Health Resources Availability Monitoring System (HeRAMS) – Yemen, November 2016, https://www.who.int/hac/crises/yem/sitreps/yemen-herams-infographic-november2016.pdf?ua=1

2 Yemen Economic Monitoring Brief – Winter 2019 (Accessed March 2019)https://reliefweb.int/report/yemen/yemen-economic-monitoring-brief-winter-2019-enar

3 Naseeb Qirbi and Sharif A Ismail et al.; Health Policy and Planning (2017) https://academic.oup.com/heapol/article/32/6/911/3591753

01 COMPLICATED DELIVERY


METHODOLOGY AND LIMITATIONSMethods Information was collected between November 2018 and February 2019. 10 semi-structured individual interviews with patients, caretakers and medical staff in MSF’s Taiz Houban mother and child hospital in Taiz governorate, and 10 semi-structured individual interviews with patients and staff in an MSF-supported hospital in Abs, Hajjah governorate.

Additional information Health data and indicators from MSF medical reports from these facilities were collected between 2016 and 2018.

Patient samplingConvenience sampling of patients and caretakers was used in the neonatal, maternal and paediatric departments within the two hospitals.

Limitations and potential biasThe locations were chosen on the basis of MSF’s presence at the facility. It was not possible to access the wider community to assess their barriers to accessing healthcare. The issues raised cannot be said to be representative of the challenges facing mothers and children across the entire country. The report also cannot conclude which barriers to healthcare had a greater impact on mothers’ and children’s ability to reach the MSF facilities compared to others.

Although this report focuses specifically on MSF’s work in both the Taiz and Hajjah governorates, the conclusions and recommendations of this report are drawn from MSF’s operational experience throughout the country.

Having interviewed solely those who managed to access an MSF-run/supported facility, this report likely underestimates the scale of the challenges facing those who never make it to an MSF facility. As the facilities chosen were analysed with a focus on the provision of care to mothers and children, it has not been possible to compare their access to healthcare to that of adult males.

Participants were also aware that the interviews were being conducted by MSF, which possibly led to some social desirability bias in the findings.

MSF has scaled up its work in Yemen since the conflict escalated in 2015. Today, MSF runs 12 hospitals and health centres across the country.

20

81,102 2,200

700

119,113

116,687

11

MSF IN YEMEN

MSF also provides support to more than

hospitals or health facilities across

governorates: Abyan, Aden, Amran, Hajjah, Hodeidah, Ibb, Lahj, Saada, Sana’a, Shabwah and Taiz.

From March 2015 to December 2018, MSF teams performed

surgical interventionsProvided treatment to

patients with injuries related to war and violence

As of 2019, MSF has

international and locally-hired staff in Yemen

Ministry of Health staff across the country.

newborn babies

68,702Delivered

and provides incentive payments to

and cared for more than

suspected cholera cases.



02


Taiz Houban mother and child hospital provides

free healthcare to children under five and women of

reproductive age, including the management of complicated

deliveries, neonatal care and a therapeutic feeding

programme. Since opening, demand for these services has

been high and has increased year on year – doubling from

4,100 deliveries in 2016 to 8,443 deliveries in 2018. In

2018 alone, the hospital saw 6,915 inpatient admissions and

admitted 1,432 malnourished children to its therapeutic

feeding programme.

In the district where the hospital is located, there is no

public hospital for a population of approximately 263,871.

Given the lack of public hospitals, the number of referrals

made by MSF from Taiz Houban to private hospitals has

also been increasing year on year since 2015. In 2018, MSF

referred 3,322 patients to private health facilities to receive

care that it lacked the capacity to provide.

Returning from a recent visit to Taiz Houban, Christian

Katzer, MSF’s operations manager for Yemen described

the experience of one patient: “I was particularly touched

by the story of one heavily pregnant woman. This woman

came from some distance away and had spent a lot of

money on transport to reach MSF’s mother and child

hospital – money that the family had had to borrow from

neighbours. When they reached the hospital, we had so

many women giving birth that we had actually had to close

our maternity admissions. The 130-bed hospital was at

full capacity. It’s heartbreaking for our staff to have to

turn away pregnant women who are desperately in need

of medical care. In the end, we were able to find space for

the woman to give birth, but it isn’t always possible.”5

Taking a look at two facilities where MSF is providing free healthcare – the MSF-run Taiz Houban mother and child hospital and the MSF supported hospital in Abs – offers an insight into some of the challenges facing mothers and children in Yemen.

MSF established its Taiz Houban mother and child hospital

in late 2015, converting a local hotel into a 130-bed

hospital and trauma centre to try and address some of the

healthcare needs in Taiz governorate. Houban is a suburb

of the city of Taiz, which has been divided by an active

frontline since 2015. Fighting has left many health facilities

out of operation or out of reach and displaced many

healthcare workers from the city. Those facilities that still

function often lack vital drugs and staff.

Health facilities themselves often come under attack.

On2 December2015,anairstrikebytheSELChitthe

immediate vicinity of an MSF tented clinic located in

Houban. The attack injured nine people including an MSF

health educator and a guard. Although airstrikes have

significantly reduced in frequency over the past two years

in Taiz governorate, fighting on the frontline of the city has

made Taiz one of the most dangerous regions of the country.

“Taiz used to be one city. Houban is on the outskirts of the city, and when the frontline cut the city in two, most if not all of the surgical hospitals were left on the other side of the frontline. On the Houban side, where we are now, there was no public hospital providing any maternal or paediatric care. Now what used to be a 10-minute drive across the city takes up to seven hours, over and around the mountains.”

Karolina, MSF head nurse, Taiz Houban4

4 Interview with MSF head nurse Karolina at Taiz Houban, November 2018

5 Interview with MSF operations manager Christian Katzer at Taiz Houban, April 2018

02 TAIZ HOUBAN MOTHER AND CHILD HOSPITAL AND ABS HOSPITAL, HAJJAH


YEMEN HAJJAH

Abs

Al-Mahabis

Mustaba

Al Hadad

Harad

Hayran

Harad

N2

2

5

A 52

S 2211

S 2311

Road

Frontline


Mawza

Dhubab

Al Mukha

Al Ma’afer

Al Wazi’iyah

Ash Shamayatayn

Al Mawasit

SamaAs Silw

Sabir Al

Hayfan

Dimnat Khadir

Mawiyah

At Ta’iziyah

IBB

AL HUDAYDAH

AL DHALE’E

Shara’b ArRawnah

Shafa’b As Salam

Maqbanah

Jabal Habashy Sabir Al

Mawadim

Al Misrakh

Ad DimnahAl Misrakh

Mawiyah

Yafrus

At Ta’iziyah

TAIZZ

YEMEN TAIZ

Taiz

Taiz Houban

Bab Musa

Sanaa Road

60 Street

District Boundary

Roads

Contested area

Governorate Boundary

Since opening, demand for the services has been high and has increased year on year – doubling from

deliveries in 2016 to

deliveries in 2018. In 2018 alone, the hospital saw

4,1008,443

6,915

1,432inpatient admissions and admitted

malnourished children to its therapeutic feeding programme.


In Hajjah governorate, MSF has been supporting Abs

hospital since 2015 in collaboration with local health

authorities.

Abs is located in the northwest of Yemen. Bordering Saudi

Arabia, the area has seen some of the conflict’s worst

violence, with airstrikes and displacement a feature of life

for its residents. Between 26 March 2015 and 24 March

2018, the Yemen Data Project reported 1,617 airstrikes

in the governorate. Following an increase in shelling from

the Saudi border in March 2015, large numbers of people

fled towards the south of the governorate, which led to the

establishment of settlements for internally displaced people

(IDPs) in the region.6

Before 2015, the governorate – specifically its western

areas – was affected by malnutrition and scarcity of water.

Now, as a result of the conflict, both displaced people and

host communities suffer from the decreased availability of

healthcare and the rising prices of basic commodities.

Abs hospital was bombed by the SELC in August 2016,

killing 19 people and wounding 24. On 12 June 2018, an

MSF cholera treatment centre was again attacked by the

SELC. Fortunately no one was killed in this attack as the

centre was not yet open.

After increasing the capacity of Abs hospital from 30 beds

to 200 today, MSF supports the emergency room, inpatient

department, operating theatre, maternity ward, inpatient

therapeutic feeding centre, laboratory and sterilisation

unit, as well as outreach activities in the surrounding areas.

A referralsystemallowsemergencycasestobetransferred

to HajjahorSana’a.

6 Yemen Data Project, http://yemendataproject.org/data/, accessed 5 March 2019


Two mothers with their children inside the MSF run

Mother and Child Hospital in Taiz Houban. Yemen

© M

atteo Bastian

elli

“Imagine my situation; imagine how painful this

all was in my state of pregnancy, being delayed

at checkpoints like this. I suffered a lot, with the unpaved roads and the

checkpoints.”


services within the community, women are waiting

until the last minute to make the dangerous journey

to receive care.”7

Traditionally, women in Yemen give birth at home with the

assistance of birth attendants, rather than delivering in

hospital. When complications occur, access to care was a

much simpler process before the outbreak of the conflict

than it is now.8 Current difficulties in accessing healthcare

mean that medical complications during pregnancy have

become much more deadly.

As a result of not being able to access basic emergency

obstetric and newborn care, 70 percent of women arriving

at MSF’s Taiz Houban hospital suffer from life-threatening

complications including obstructed labour, prolonged

labour, pre-eclampsia, eclampsia, uterus rupture and

post-partum bleeding. As a result, they need high-level

comprehensive emergency obstetric and newborn care.

Without community-based health clinics providing

antenatal care, complicated pregnancies go undiscovered

until it is time to give birth. Adequate screening would

allow pregnant women to be referred to MSF’s Taiz

Houban hospital in time and would likely reduce the

pressure on the hospital, as it would have fewer emergency

cases to care for.

MSF nurse Zainab, who works in Taiz Houban, describes a

recent patient: “I remember a woman who tried to give birth

at home but could not due to complications. Her home was

far from the MSF hospital and, when she arrived, she was

suffering from uterine rupture and her baby was dead. The

doctors hurried to perform an emergency operation for her

as she was bleeding heavily. We expected the woman to die,

but she lived.” 9

“I have four children at home and the fifth one is here in the hospital. It took us six hours to get here. We do not have [hospitals in our village]. The hospital is so far.” Khamisa, patient at Taiz Houban, from Al Wa’shah, Taiz 10

Before the escalation of the conflict, Taiz governorate had nine public hospitals. Five of these were located in Taiz city, which is home to some 615,000 people, according to the country’s 2014 census.

As of March 2019, no public hospital in Taiz governorate

is fully functioning. Three of the five hospitals in Taiz city

centre remain partially open, with support from MSF

and other international non-governmental organisations

(INGOs). However, the hospitals do not provide the

same level of services they did before the conflict and

are not easily accessible for those living across the

frontline in Houban. From time to time, MSF’s Taiz

Houban hospital receives patients who have crossed the

frontline – not only to receive better quality healthcare,

but also to be in a safer hospital environment. MSF-

supported hospitals in Taiz city centre are hit by warring

parties regularly and their safety and security is often

compromised by armed groups operating in and around

the hospital compounds.

MSF’s hospital manager in Taiz Houban describes the

situation in Taiz governorate: “Primary healthcare

services are not fully functioning and have not been in

a long time. More often than not they are not staffed

by healthcare professionals and, if they are, the staff

are not usually trained in the management of the cases

presented. Without sufficient capacity or trust in these

7 Interview with Taiz Houban hospital manager Rachel at Taiz Houban, November 2018

8 Naseeb Qirbi and Sharif A Ismail et al.; Health Policy and Planning (2017) https://academic.oup.com/heapol/article/32/6/911/3591753

9 Interview with MSF nurse Zainab at Taiz Houban, November 2018

10 Interview with patient Khamisa from Al Wa’shah village, Taiz, at Taiz Houban, November 2018

03 ACCESS TO MEDICAL CARE


As in Taiz governorate, the lack of functioning health

centres is also a challenge facing communities in Abs,

Hajjah governorate. Women arriving at the MSF-supported

maternity ward in Abs often describe the long and difficult

journeys they made to get there.

Sadeqa, an MSF midwife in Abs, says: “This distance from

medical care is a big problem. The areas around Abs are

mountainous. Sometimes patients are prevented from

travelling because of airstrikes and clashes. Many of the

roads they use are unpaved and are very bad after it rains.

Also, patients do not go out at night because they are afraid

they could be attacked. Once it happened that a car was hit

by an airstrike, killing everyone inside.” 11

“Imagine my situation; imagine how painful this all was in my state of pregnancy, being delayed at checkpoints like this. I suffered a lot, with the unpaved roads and the checkpoints. If this war was not happening, I could go to any public hospital. But in this situation of war, with checkpoints and gunshots, we arrived at Taiz Houban in a state of panic.” Eftekar, patient at Taiz Houban, from Al Wazeera, Ibb 12

“A woman came here six months ago. Her family took her to the health centre. They gave her oxytocin. Her uterus was ruptured. When she arrived here, it was too late and she died. They came here with a hope that they could save her, but she and her baby died at the gate of the hospital.” Safana, MSF midwife, Abs hospital 13

11 Interview with MSF midwife Sadeqa at Abs Hospital, Hajjah, January 2019

12 Interview with patient Eftekar from Al Wazeera, Ibb, at Taiz Houban, November 2018

13 Interview with MSF midwife Safana at Abs Hospital, Hajjah, January 2018

Bra’ah Fawzan - 6-day-old breathes from an oxygen tube in the emergency room of Abs Rural Hospital, which has been run by MSF since 2015. Bra’ah came from Khiran area by a taxi, where the roads are very rough. Khiran area is a contact area and it was bombed by more than 50 airstrikes. It is about 100 km away from Abs district.


© XXXX

“It was the time to give birth to the baby.

We were looking for a car. If we arrived

late at the hospital, no one knew what

would happen.”

© M

oham

med

Alm

ahd

i/MSF


52 percent of Yemen’s population were living on less than

US$1.90 per day.19

In Hajjah and Taiz governorates, daily labourers can expect

to earn between 2,000 (US$3.4) and 6,000 (US$10.3) rials

per day, depending on whether they are unskilled labourers,

farmers or builders.20

“It was the time to give birth to the baby. We were looking for a car. If we arrived late at the hospital, no one knew what would happen. We found a car and the driver asked for 20,000 rials (US$35), so we agreed.” Maryam, patient at Abs hospital, from Hajjah21

Today, the cost of private healthcare in Taiz governorate

varies, but can often be costly. In one local hospital, the cost

of an uncomplicated caesarean section is approximately

US$160; the cost of neonatal care with an incubator is

US$16-24 per day; while one night in the intensive care

unit costs around US$105. The overall cost of admission

to a private hospital for a few days could be US$400-500,

“The war has had a terrible impact on the whole of Yemeni society – in terms of the blockade, increased commodity prices, insecurity and everything else that comes with conflict. People are very poor and cannot afford the cost of a single medicine.” Eftekar, patient at Taiz Houban, from Al Wazeera, Ibb14

The high mortality rates witnessed by MSF in Taiz Houban

are likely underpinned by the economic vulnerability faced

by many families, which limits people’s freedom to choose

which medical facility to attend, if any. As of January 2019,

the Yemenirial’spurchasingpoweris148percentlower

than in the pre-crisis period. The average weekly food bill

forYemenifamilieshasrisenby96 percent,whiletheprices

of diesel and petrol are up 98 percent and 106 percent

respectively.15 Since 2014, Yemen’s gross domestic product

has fallen by 29 percent, with the conflict causing wide-

spread disruption to formal economic activities.16

Before the escalation of the conflict in 2015, most medical

services in Yemen were provided by private health facilities,

with the remainder provided by the Yemeni public health

service. Private healthcare was not free, but it was affordable

for many people. While private and public healthcare was

sometimes unavailable in rural areas, transport to nearby

towns was both available and affordable.

As highlighted in MSF’s report Saving lives without salaries,

public workers including healthcare professionals, teachers

and other government employees have received partial or no

salaries since August 2016.18 In 2018, payments of salaries

were resumed for employees in the areas nominally under

the control of the internationally recognised government

of Yemen, but public sector workers in other areas are still

waiting for their salaries to be paid in full, according to MSF

Yemeni staff.

As public sector salaries accounted for 37 percent of public

expenditure in 2012, the reduced payment of these salaries is

having a major impact on Yemen’s population. In 2018, some

14 Interview with patient Eftekar from Al Wazeera, Ibb, at Taiz Houban, November 2018

15 WFP Yemen – Monthly Market Watch – January 2019, https://www.wfp.org/content/yemen-monthly-market-watch-2018, accessed 2 March 2019

16 Yemen Economic Monitoring Brief – Winter 2019 (Accessed March 2019)

https://reliefweb.int/report/yemen/yemen-economic-monitoring-brief-winter-2019-enar

17 Increasing Health Care Access in Yemen Through Community-Based Health Insurance (2016), Matthew Fuss, www.repository.law.indiana.edu/ijgls/vol23/iss2/14/

18 Yemen: Saving lives without salaries (MSF 2017), https://www.msf.org/yemen-government-health-staff-are-saving-lives-without-salaries

19 The World Bank, Yemen’s Economic Outlook - October 2018, https://www.worldbank.org/en/country/yemen/publication/economic-outlook-october-2018

20 Daily rates derived from conversations with MSF staff in Taiz Houban and Abs

21 Interview with patient Maryam from Hajjah, at Abs hospital, January 2019

04 THE IMPACT OF THE ECONOMIC COLLAPSE ON MEDICAL CARE


which could rise as high as US$1,500 for complicated cases

requiring specific procedures and a longer hospital stay.

As demand continues to outpace capacity, MSF’s ability

to refer patients could plateau, leaving nowhere to refer

complicated cases.

MSF’s hospital manager in Taiz Houban says: “Previously

people had a little bit of money, allowing them to seek

care in local private clinics and afford transport. Now, as

resources are tighter, they are delaying their arrival at the

remaining medical facilities, including our one, which is free.

One example is a child [being cared for at a private clinic] in

Sana’a, where the family paid for the operation but could not

afford the aftercare. So they disconnected the child from

the oxygen and intravenous fluids and travelled for eight

hours to bring the child here to us. When the child arrived, it

was at its last breath. They brought the child here thinking

we could care for the child – which we could and would have

done – but at that point it was too late. We did what we

could, but sadly the child passed away. It is distressing that

families have to go to these extremes.”22

The damage to Yemen’s economy – compounded by the

lack of public sector salaries – has also affected Hajjah

governorate, where many people struggle to provide the

basics for their families.

MSF midwife Sadeqa in Abs hospital says: “Most of the

medical facilities that remain in the governorate are private.

The public ones are either closed or not equipped with

medical staff or equipment, and are not ready to receive

patients. The private facilities that still function ask the

patients to pay a lot of money. People are poor. Some of

them do not go to hospitals because they cannot pay for

the expense,orelsetheycomeherebecauseitisfree.”23

22 Interview with MSF midwife Sadeqa at Abs Hospital, Hajjah, January 2019”


“The driver told us that the route is dangerous and they would be taking a risk by driving us to the hospital. We were so scared because the coalition attacks anything. They attack the passengers, the houses, the hospitals and the health centres.”


Kholah and Saher were malnurished and dehidrated.

Once in hospital they were fed milk, as they hovered

between life and death.

© M

SF


“The long distances, the explosions and the clashes make the patients come late. We ask them ‘Why are you late? Why did you not come early?’ They answer that they travelled from 6 am and arrived at midnight. The clashes and the blocked roads made them late. Therefore we receive terrible cases: premature birth, bleeding, dead fetus. Mothers lose their lives. When we ask their families why they came late, they tell us it is because of the security situation and their economic conditions.” Zainab, MSF nurse, Taiz Houban24

Due to the myriad armed groups and ongoing hostilities,

travelling to a medical facility can be a dangerous

experience, especially for those crossing frontlines. The

multiple checkpoints between territories controlled by

different warring parties are often points of extreme

tension and violence. Over the course of 2018, 4,836

incidents of armed violence had a significant impact on the

civilian population of Yemen. Thirty-two percent of these

violent incidents involved women and children.25

While the majority of those who attended MSF’s Taiz

Houban hospital did not have to cross frontlines some of

those that did spoke of the risks. Abdulkhabeer, a patient

caretaker from Ibb governorate says: “We left at one in the

early morning and, while we were on the road, bandits shot

at our car, three bullets, but we survived.” 26

Eftekar, a patient, also from Ibb governorate echoed the

risks of reaching Taiz Houban: “The road from home to the

hospital is not safe. In the past, we can take pregnant women

to the hospitals at night but now we cannot, as the cars are

not allowed to move at night. We keep watching the pregnant

women in our community suffering and dying. If it is a critical

case, we can take them by car at night, but there is a risk we

will be shot. Movements are allowed only from 6 am to 6 pm.

Before the war, it was safe to take the pregnant women to

hospital in Al Rahedah [40 km from Houban] anytime.” 27

In Abs hospital, Hajjah, multiple patients spoke of their

fear of the threat of airstrikes in the governorate when

attempting to access healthcare. Many said they would

not risk travelling at night for fear of robbery or being shot

approaching a checkpoint in the dark.

Khattab, MSF’s mental health manager in Abs, describes

the situation: “Abs hospital itself was targeted before, and

the whole Abs area has suffered many airstrikes over the

course of the war. This has put huge pressure on people

from the governorate and makes people afraid they will be

attacked on the road or even that the hospital will be hit

again. We have many patients showing symptoms of post-

traumatic stress disorder who are extremely fearful of loud

noises. Even the sound of a motorbike starting can be very

upsetting for patients.”28

“The driver told us that the route is dangerous and they would be taking a risk by driving us to the hospital. We were so scared because the coalition attacks anything. They attack the passengers, the houses, the hospitals and the health centres.” Maryam, patient at Abs hospital, from Hajjah 29


25 Civilian Impact Monitoring Report Annual 2018 (Accessed March 2019) https://www.humanitarianresponse.info/en/operations/yemen/document/civilian-impact-monitoring-report-annual-2018

26 Interview with caretaker Abdulkhabeer from Al Mudaikera, Ibb, at Taiz Houban, November 2018

27 Interview with patient Eftekar from Al Wazeera, Ibb, at Taiz Houban, November 2018”

28 Interview with MSF mental health manager Khattab at Abs hospital, Hajjah, February 2019”

29 Interview with patient Maryam from Hajjah, at Abs hospital, Hajjah, February 2019”

05 SAFETY AND SECURITY WHEN SEEKING MEDICAL CARE

© N

uh

a Moh

amm

ed

“People are poor. Some of them do not go to hospitals because they cannot pay for the expense, or else they come here because it is free.”24 Complicated delivery The Yemeni mothers and children dying without medical care


HUMANITARIAN ACCESS IN YEMENDespite the needs that exist in Yemen, access by humanitarian organisations to the most vulnerable populations is often hampered by restrictions placed on them by parties to the conflict.

For MSF teams in Yemen, access – especially to rural and district communities in areas close to frontlines – remains a significant challenge.

Overly bureaucratic and cumbersome procedures delay the issuing of visas to Yemen for medical and non-medical humanitarian staff. This has a deeply negative impact on the capacity of MSF to deliver quality, timely medical care to our patients in projects around the country.

Similarly, bureaucratic delays by authorities under the control of the parties to the conflict impede the rapid importation and movement of lifesaving medical supplies into and around the country. This is having a negative knock-on effect – threatening to disrupt medical supplies for our activities and slowing down our ability to swiftly respond to outbreaks and other medical emergencies.

Taken together, these constrain humanitarian operations in the country and threaten to compromise the provision of uninterrupted medical care in MSF facilities.

Mother’s and their children waiting their turn at the triage and waiting area in the

outpatient department in the mother and child Hospital. Taiz Houban, Yemen.


MSF’s hospital manager at Taiz Houban says: “Last month

in our emergency room we had 10 cases of children arriving

dead. Of those 10 deaths, four were clearly the result of

travelling for several days to get here. If they had lived closer

to MSF’s hospital or had had the ability to pay for transport

or medicines to treat a simple chest infection, it would not

have resulted in such a serious outcome as the child dying.”30

ABSIn the MSF-supported hospital in Abs, MSF has witnessed

a similar situation unfold. Between 2016 and 2018 the

facility recorded the deaths of 705 people – 19 mothers,

269 children and 417 newborns. Among the 417 neonates,

106 died on the day of arrival.

In the neonatal department, 65 percent (1,338/2,058)

of all admissions during the period were of children born

outside the MSF-supported hospital, many presenting with

low birthweight. In mothers, pre-eclampsia, eclampsia and

conditions such as post-partum bleeding and rupture of

the uterus are not uncommon. Within MSF’s maternity

department in Abs, 19 percent (2,312/12,306) of children

born in the hospital were of a low birthweight.

TAIZ HOUBANMSF is witnessing the deadly consequences of people’s

difficulties accessing medical care on a daily basis. Between

2016 and 2018, there were 860 deaths of reported in Taiz

Houban – 17 mothers, 242 children and 601 newborns.

Of these deaths, almost one-third (227) were children and

newborns who were dead on arrival.

The number of children and newborns who were dead

on arrivalatTaizHoubanincreasedfrom52in2016,to

72 in 2017,to103in2018.

The desperate need for medical care of the children arriving

at Taiz Houban is further exemplified by the 170 children and

newborns who were alive on arriving at the facility but died

within the following six hours. Children under one month old

made up the majority of these deaths (71 percent).

Overall, newborn babies – under the age of one month old

– accounted for 71 percent of child deaths in Taiz Houban

(601/843). Many newborns brought to MSF for care have a low

birthweight or were born prematurely, either at home or in small

private clinics. The most common causes of deaths in neonates

were prematurity, birth asphyxia and severe infections (sepsis).

30 Interview with Taiz Houban hospital manager Rachel at Taiz Houban, November 2018

06 MEDICAL CONSEQUENCES OF IMPEDED ACCESS TO HEALTHCARE

Between 2016 and 2018, there were

deaths reported in Taiz Houban

mothers

860

17242601

227

children and

newborns. Of these deaths, almost one-third

were children and newborns who were dead on arrival.


© M

atteo Bastian

elli


3-year-old Hassan, suffering from Thrombocytopenia Anaemia and malnutrition, is seen playing with

his aunt on a bed inside the Inpatient Therapeutic Feeding Center, a department of the “Mother and

Child” Hospital. The aunt brought him to the hospital with very challenging condition after she have been told, in other facilities, “that there was nothing to do

for him.” MSF doctors managed to save his life and now they call him the “miracle baby”.

Taiz Houban, Yemen

“Taiz used to be one city. Houban is on the outskirts

of the city, and when the frontline cut the city in

two, most if not all of the surgical hospitals were

left on the other side of the frontline.”


07


“When we look at our statistics, we would have to build five mother and child hospitals in Taiz governorate to provide enough care and coverage for the people of the governorate, but that is not possible. A more coordinated approach and a stronger presence of other INGOs could be a way to strengthen primary healthcare services and allow us to focus on treating the complicated cases.” Rachel, MSF hospital manager, Taiz Houban31

The warring parties in Yemen and their international

backers have allowed a situation to unfold where one of the

country’s most vulnerable sections of society – mothers and

children – are unable to reach adequate medical care in a

safe and timely manner, with deadly consequences.

Humanitarian organisations in Yemen operate in an

environment of deep suspicion and intimidation – often

hampering their ability to reach the most vulnerable. Although

MSF maintains a presence in some of the most challenging

areas of Yemen, it is limited in its access to rural communities,

especially those living close to areas of active fighting.

Despite the efforts of international organisations and

INGOs in the country, the obstruction of humanitarian

assistance and the lack of access to communities living near

frontlines is crippling their ability to improve overall health

outcomes for the Yemeni population.

RECOMMENDATIONS• International humanitarian law must be respected by all

parties to the conflict. Attacks on medical facilities must

cease and the protected status of civilians and medical

and humanitarian staff must be respected. As part of this,

from the local to international level, the warring parties

need to improve their awareness of and obligations under

international humanitarian law and abide by them.

• A quicker and more transparent procedure is needed for

humanitarian staff to be able to obtain the necessary visas

to enter Yemen.

• Additional humanitarian organisations should begin

operations in Yemen and their registration process should

be facilitated and expedited by local authorities.

• Humanitarian actors in Yemen should increase efforts to

ensure that experienced and specialist staff are in place

to oversee the implementation and quality control of

humanitarian activities.

• The importation of lifesaving drugs and their movement

around the country should be unburdened from any

unreasonably protracted bureaucratic procedures and/

or duplications of administration that lead to ruptures in

supply and shortages.

• Humanitarian organisations’ access, and permission to

work in, rural and district-level areas needs to be opened

up by the warring parties. This would allow for adequate

implementation and supervision of medical humanitarian

programming such as community primary healthcare

clinics, health promotion activities, outreach activities

and vaccination initiatives.

31 Interview with Taiz Houban hospital manager, Rachel, at TaizHouban,November2018

07 CONCLUSION

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